1. CYPRESS COLLEGE LONG TERM CARE & THE HEALTH INFORMATION PROFESSIONAL

2. PRESENTED BY Khaleelah Wagner, RHIA Training Coordinator, AHIS A nderson H ealth I nformation S ystems, I nc. 940 W. 17 th Street, Suite B Santa Ana, California 91706 Phone 714-558-3887 Fax: 714-558-1302 Email: khaleelah@ahis.net, office@ahis.net or trisha@ahis.netkhaleelah@ahis.netoffice@ahis.net trisha@ahis.net

3. DATE & LOCATION October 9, 2008 Cypress College

4. AHIMA DOMAINS Identify Health Information Systems items for a Long Term Care Facility Identify the rules and regulations and how you stay “in touch with regulations” Identify quality assurance and improvement systems and will practice documentation review Identify health information systems and tasks for the HIM Department

5. AHIMA DOMAINS -2 Assist in identifying a schedule for a LTC facility that includes change of condition Review the Change of Condition Instruction and receive guidance to conduct onsite visit with an HIM Consultant Present data both manual and verbal

6. HOW SHOULD I DO IT? Attend a presentation on the HIM Consultant in Long Term Care Review the ppt. and the handouts Practice one quality of documentation review and prepare for onsite assignment Attend onsite assignment Prepare a summary of the key points learned, identify compliance items and best practices

7. EVALUATION CRITERIA 1.Attend the LTC presentation. Prepare a one-paragraph summary of the most important item learned. 2.Make a written list of organizational items that would be the same if you were in acute hospital setting, clinic, etc.

8. EVALUATION CRITERIA -2 3.Practice of change of condition in classroom setting – identify questions. Use those questions and prepare a one-page summary of the Change of Condition review done onsite with the consultant. 4.Conduct change of condition for 5 residents and tabulate results.

9. EVALUATION CRITERIA -3 5.Identify the schedule of the LTC – Health Information/Record Designee. Assess the completeness and determine if carried out timely and completely. Prepare a one- paragraph summary re: your thoughts re: scheduling process. 6.Prepare a summary of onsite visit with consultant that describes the results of the onsite visit and present the findings that identifies “system issues” and Best Practices.

10. TASKS – ACTIVITY 1. Attend the LTC presentation. 2. Prepare a one paragraph summary of the most important item learned. 3. Identify tasks in the LTC facility – HIM/Record Department that would be the same as an acute hospital setting, clinic, etc. **(have the list prepared prior to consult visits)**

11. TASKS – ACTIVITY -2 4. Conduct Change of Condition for 5 residents and tabulate results. 5. Identify the HIM/Record Designees’ last two Change of Condition audits. Identify the deficient areas. 6. Review the schedule of audits/monitors from the HIM/Record Designee and review the Audit book re: timeliness and follow-up action.

12. TASKS – ACTIVITY -3 Identify five items you learned and/or best practices you observed from the HIM/Record Consultant and/or the HIM/Record Designee’s work in the facility.

13. OFFSITE AHIS RESOURCES Anne Soukup Office Manager re: Billing - Contracts Office 714-558-3887 Email: bosslady@ahis.netbosslady@ahis.net Trisha Bui Office Assistant – Part time Office 714-558-3887 Email: trisha@ahis.nettrisha@ahis.net

14. ANDERSON HEALTH INFORMATION SYSTEMS Anderson Health Information Systems, Inc. (AHIS) will assist __________________ Healthcare to meet the immediate and long range goals of quality improvement through consultation

15. RE-ENGINEERING OF THE HEALTH INFORMATION AHIS has Health Information/Record Department tools for evaluation of the Department’s systems. (H.O. #1a & #1b) Sample HI Questionnaire Summary (H.O. #1c) ________________ Healthcare’s current Department evaluation tools, policies and procedures will be reviewed/recommendations made based on your input

16. ANALYZE THE MEDICAL RECORDS SERVICES Conduct an evaluation of each of the HI/Record Department’s systems and provide input as to the suggested approaches for HI/Records in coordination with the _____________ Healthcare designated staff.

17. ANALYZE THE MEDICAL RECORD SERVICES -2 Focus items will include: schedules, efficiency and integration into the overall Quality Assurance model. (H.O. #2)

18. PERFORMANCE MEASURES Clinical Records Systems Staff Performance Measures (H.O. #3) - Criteria represent a fairly complete outline of the duties and responsibilities of the HIM Dept staff - Written in outcome oriented terms - Tied to F-tags, Title 22 and other regulatory requirements and standards of practice in the field of HIM - Key items are introduced and trained and/or evaluated based on facility needs and the experience of the staff member Orientation and Training Checklist (H.O. #4) - Tracks progress of HIM Staff Training and Skills Mastery

19. PROVIDE WORKSHOPS For HI/Record Department and clinical staff based on identified needs. Example for records staff training – coding, new regulations/requirements, audit and monitoring systems, Daily Quality Assurance AKA Change of Condition etc. Change of Condition (H.O. #5a-e)

20. PROVIDE WORKSHOPS -2 Workshops for clinical staff may be provided based on agreed topics.

21. HEALTH INFORMATION/ RECORD MANUAL – AHIS Will evaluate the current HI/Record Manual to determine if there are policies and procedures that need revision. Regulations that apply; Title 22 –State Regulations – Skilled Nursing Federal Regulations by Center for Medicare and Medicaid Services – Omnibus Budget Reconciliation Act, OBRA – F- Tags

22. REGULATIONS Hospice, Dialysis, Sub-acute Medi-Cal Regulations Joint Commission OSHA HIPAA Fire and Life Safety Disaster Planning

23. HEALTH INFORMATION/ RECORD MANUAL – AHIS -2 – Admission Monitor – Admission/7/14/21/30 Day Combined Monitor – Admission/7/14/21/30 Day Monitor – Admission/JCAHO Sub-Acute Monitor – Advance Directive/IHCI/Preferred Intensity of Care (PIC) Monitor – Behavior Drug Monitor – Bowel/Bladder Training Monitor – Care Plan Monitor – Change of Condition/Daily Quality Assurance Monitor – Clinical Record Monitor – Combined Admission Monitor – see Admission/7/14/21/30 Day Combined Monitor – Diabetic Monitor – Dialysis Monitors – Hospice Monitor – Intake/Output/Catheter Monitor

24. HEALTH INFORMATION/ RECORD MANUAL – AHIS -3 – JCAHO Sub-Acute Monitor – see Admission/JCAHO Sub- Acute Monitor – Licensed Progress Note Monitor – Option I/II – Medicare/MDS Monitor – Medication Monitor – Minimum Data Set (MDS) Monitor – Nursing Assistant Flow Sheet Monitor – Pressure Sore/Ulcer/Skin Conditions Monitor – Rehabilitation Monitor – Respite Care Monitor – Restrictive Device/Restraint Monitor – Seven/Fourteen/7/14 Day Monitor – see Admission/7/14/21/30 Day Monitor – Therapy Monitor – Treatment Monitor – Weight Monitor/Weekly Weight Monitor/Weight Log

25. HEALTH INFORMATION/ RECORD MANUAL – AHIS -4 AHIS will offer recommendations for policy/procedure updates/changes when indicated and when new regulations or interpretations are identified. AHIS will advise on current changes in our own manual and assure _____________ Healthcare is informed.

26. ASSIST With implementation of _____________ Healthcare policies and procedures, as applicable. Adapt the Medical Record Consulting processes that would compliment the Corporation’s policies and procedures. NEED TO BE KEPT CURRENT RE: _____________ CHANGES THAT AFFECT HIM/RECORD SYSTEMS.

27. CORPORATE QUALITY IMPROVEMENT PROCESS – AHIS Will collect information based on predetermined topics and criteria, provide a summary, conclusions and analysis for problem solving and follow up.

28. Coordination will be carried out with the interdisciplinary team members. AHIS will utilize _____________________ Healthcare’s Quality Indicators/Measures for care documentation. _____________ to provide guidance to AHIS in this area to assist with coordination. CORPORATE QUALITY IMPROVEMENT PROCESS – AHIS -2

29. QI INDICATORS FOR DOCUMENTATION AHIS = manual of Quality Improvement Documentation and Outcome indicators Will assist in maximizing the use of _____________ automated tools that are available. Pain Assessment (H.O. #6a) CMS – Quality of Care Management of Pain (H.O. #6b)

30. EXAMPLES OF REPORT & TRENDING Consultant will review and explain

31. COMPUTERIZATION Will evaluate the record tasks related to computerized systems

32. CONSULTANT COORDINATION & MEETING ATTENDANCE AHIS will attend meetings as designated and arranged corporate-wide participation.

33. RESOURCES Provide health information management resource materials

34. HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT Will provide the basic part of HIPAA as a part of the consultation services. AHIS has experts in the area of Transaction Code Sets, Privacy and Security.

35. HIPAA Security Rule Part of the Health Insurance and Portability and Accountability Act 1996 - Administrative Simplification - Privacy Rule enforceable April 14,2003 - Security Rule enforceable April 20, 2005*  *Small health plans enforceable April 20, 2006 HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT -2

36. HIPAA Under separate agreement, AHIS can provide an outline for HIPAA assessment, training and implementation Privacy Transaction and Code Sets Security National Provider Number Attachments AND MORE---

37. NEW & TRAINING

38. OFFSITE ASSISTANCE & TRAINING Some training maybe appropriate to be provided via Webinar. AHIS will provide Webinar training and/or offsite training via phone and instructional material. Can establish training for online computerization…if arranged.

39. OFFSITE ASSISTANCE & TRAINING -2 Webinar Schedule Dates - TBD Time - TBD

40. MANUALS Cost for AHIS Manual – with or without CD

41. QUALITY THROUGH CONSULTATION Our intent is to enhance skills, reduce costs and increase efficiency Find better ways of doing things Increase automation Assist to meet legal expectations, reduce risks Assist with compliance HAVE FUN!

42. JOIN THE CONSULTING WORLD… IT’S FUN!